Follow-Up Visits in Impoverished Patients: Synthesis of Evidence

EPB Question: In impoverished patients, what is the efficiency of treatment if they are encouraged to attend the follow-up visit, compared to no intervention within three months?

Category (Level Type)	Total Number of Sources / Level	Overall Quality Rating	Synthesis of Findings
Level I	4		The central issue of treatment efficiency improvements after follow-up visits is directly related to the concepts of patient safety and quality of care. It is evident that the avoidance of follow-up procedures may have a negative effect on the clinical outcomes of any patient. Furthermore, this effect is multiplied in the case of impoverished populations because of the overall lower frequency of visits. From the healthcare organization’s perspective, the lack of follow-up visits leads to costly readmissions. Lambeck et al. (2019) researched intervention in the form of home visits effectuated by the hospital staff, revealing no statistically significant effect of such a format. Furthermore, home visits are complicated in the age of COVID-19, which is a point of view supported by Bell et al. (2020). According to them, vulnerable patient groups can benefit from remote consultations in the spirit of telemedicine. Their empirical reproductions revealed a statistically significant reduction of reattendance when remote follow-up consultations are applied. In order to accentuate the benefits of timely intervention, hospitals will need to exhibit a stronger emphasis on the quality of care. Rantz et al. (2017) acknowledge the contribution that advanced practice nurses can make. In addition, hospitals will need better staffing policies to meet the requirements of the intervention (Sloane et al., 2018). This way, the increased number of follow-up visits will not put additional stress on the system.
Level II	1		The issue at hand has become the product of profound systemic flaws that prevent vulnerable populations from accessing healthcare in a due manner. More specifically, researchers identify serious barriers that impede the desired quality of care provision. The frequent absence of timely follow-up visits (and subsequent readmissions) is directly related to such barriers. Accordingly, for the intervention to instill the expected outcome in the long term, the approach to it needs to be equally systemic. Williamson et al. (2021) relate the tendency of missed appointments to the increased treatment burden upon the patients. More specifically, this trend is more prevalent outside emergency units. This implies that there is a lack of complete understanding regarding the importance of less acute cases. As a result of the underrated perception, vulnerable people delay their visits until the situation reaches the level of an emergency. Accordingly, a certain educational component is to be considered as part of the intervention in order to synchronize the perspectives between the system and patients.
Level III	4		The barriers to be addressed by the intervention can be both objective and subjective. George et al. (2018) investigate the perceived impediments within vulnerable patient groups. In their research, an emphasis is laid on the financial barriers that serve as the primary obstacles on the path to timely, high-quality care. Thus, even though some patients may realize the importance of follow-up consultations, their economic status does not align with such frequency. According to Aragona et al. (2020), COVID-19 put additional stress on the situation as the level of healthcare accessibility deteriorated. It is out of the medical system’s power to eliminate the economic barriers, meaning that it should seek additional avenues of patient engagement (Ofei-Dodoo et al., 2018). Dantas et al. (2018) concur with the idea of the severe socioeconomic status impact on the attendance of appointments, highlighting the importance of the format change.
Level IV	0
Level V	1		The planned interventions are to see an increased engagement of advanced medical professionals, namely registered nurses. They possess the required expertise through which the intervention should be modified to meet the specific needs of a certain community. Advanced practice nurses are on the front line of the system, meaning that they serve as a bridge between patients and other members of medical teams. They are aware of both parties needs. Vulnerable populations should be one of the priorities for such policy development initiatives. In the context of follow-up visit frequency increase, advanced practice nurses provide an invaluable influx of relevant data regarding the barriers faced by the patients. The key to a successful intervention lies at the intersection of APRN expertise and healthcare accessibility strategies. In other words, advanced practice nurses should be in the vanguard of intervention planning, implementation, and evaluation.

Overall, the current landscape of the healthcare system exhibits a strong need for profound interventions that would promote the accessibility of care for vulnerable populations. In this regard, one of the key issues is related to the lack of follow-up consultations that undermines the health of financially insecure patients. As evidence suggests, this tendency is particularly strong outside of acute and emergency care. Spoken differently, impoverished patients tend to understate the severity of their issue unless an immediate threat to a person’s life is encountered. As a result of insufficient financial resources, they postpone their visits to medical institutions, limiting them to a single session. At the same time, the body of evidence suggests that follow-up procedures are necessary for supporting the initial progress of the treatment plan. Without them, the condition sees an increased chance of relapse with subsequent readmissions as a common implication, which equally becomes a costly ordeal for both patients and organizations.

The proposed intervention seeks to increase the rate of follow-up consultations among vulnerable patient groups. In most cases, this implies that the person is to return physically to the medical unit for a scheduled follow-up appointment. However, this intervention suggests a higher level of flexibility in this regard. There is a growing body of evidence in favor of new formats of practitioner-patient interaction that can mitigate the effect of economic barriers. From one perspective, some researchers suggest that home visits may be a fitting solution to the problem. Nevertheless, evidence suggests that this format does not have a direct effect on patient outcomes. Furthermore, the present reality of the COVID-19 pandemic has changed the rules of the craft. As such, modern researchers discuss the benefits of remote follow-up consultations. As per the present intervention, they will play an important role in engaging vulnerable patient groups. Remote procedures can account for the majority of interactions, especially when the situation is not threatening and requires an immediate physical examination. Advanced practice nurses will play the role of leading consultants and decision-makers in the development and implementation of the policy.

References

Aragona, M., Barbato, A., Cavani, A., Costanzo, G., & Mirisola, C. (2020). Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties. Public Health, 186, 52-56. Web.

Bell, L. C., Norris-Grey, C., Luintel, A., Bidwell, G., Lanham, D., Marks, M., Baruah, T., O’Shea, L., Heightman, M., & Logan, S. (2021). Implementation and evaluation of a COVID-19 rapid follow-up service for patients discharged from the emergency department. Clinical Medicine, 21(1), 57-62. Web.

Dantas, L. F., Fleck, J. L., Oliveira, F. L. C., & Hamacher, S. (2018). No-shows in appointment scheduling–a systematic literature review. Health Policy, 122(4), 412-421. Web.

Diez-Sampedro, A., Gonzalez, A., Delgado, V., Flowers, M., Maltseva, T., & Olenick, M. (2020). COVID-19 and advanced practice registered nurses: frontline update. The Journal for Nurse Practitioners, 16(8), 551-555. Web.

George, S., Daniels, K., & Fioratou, E. (2018). A qualitative study into the perceived barriers of accessing healthcare among a vulnerable population involved with a community centre in Romania. International Journal for Equity in Health, 17(1), 1-13. Web.

Lembeck, M. A., Thygesen, L. C., Sørensen, B. D., Rasmussen, L. L., & Holm, E. A. (2019). Effect of single follow-up home visit on readmission in a group of frail elderly patients: A Danish randomized clinical trial. BMC Health Services Research, 19(1), 1-10. Web.

Ofei-Dodoo, S., Kellerman, R., Hartpence, C., Mills, K., & Manlove, E. (2019). Why patients miss 8 scheduled outpatient appointments at urban academic residency clinics: A qualitative evaluation. Kansas Journal of Medicine, 12(3), 57. Web.

Rantz, M. J., Popejoy, L., Vogelsmeier, A., Galambos, C., Alexander, G., Flesner, M., Murray, C., Crecelius, C., Ge, B., & Petroski, G. (2018). Impact of advanced practice registered nurses on quality measures: The Missouri quality initiative experience. Journal of the American Medical Directors Association, 19(6), 541-550. Web.

Sloane, D. M., Smith, H. L., McHugh, M. D., & Aiken, L. H. (2018). Effect of changes in hospital nursing resources on improvements in patient safety and quality of care: A panel study. Medical Care, 56(12), 1001. Web.

Williamson, A. E., McQueenie, R., Ellis, D. A., McConnachie, A., & Wilson, P. (2021). ‘Missingness’ in health care: Associations between hospital utilization and missed appointments in general practice. A retrospective cohort study. PloS One, 16(6), e0253163.